New three-in-one HIV drug could avert over 300 000 infections

Health Minister Zweli Mkhize launched a new three-in-one HIV drug that could help people suffer fewer side effects and avert more than 300 000 new infections in the next two decades.

According to a press statement released by the Bhekisisa Centre for Health Journalism on Wednesday 27 November, Mkhize was expected to kick off South Africa’s rollout of the HIV tablet in KwaZulu-Natal’s Ugu District. 

The tablet will combine a relatively new antiretroviral (ARV) called dolutegravir with the more commonly used ARVs, tenofovir and lamivudine. 

Most South Africans on HIV treatment already use one of these drugs alongside a third called efavirenz. 

New HIV drug better at dropping the level of virus in patients 

A 2019 research review by the World Health Organisation (WHO) found that dolutegravir, also called DTG, was better than efavirenz at dropping the level of HIV in people’s blood. In other words, it can be virally suppressed.

Once suppressed, HIV sufferers can’t transmit the virus, which is partly why a modelling study presented at the 2018 International Aids Conference found switching to include DTG as part of standard treatment in South Africa, could diminish new infections. 

The research also found the move to dolutegravir was likely to prevent tens of thousands of Aids-related deaths in the country between 2019 and 2038.

Patients less likely to develop resistance to new HIV drug

Patients on DTG are less likely to develop resistance to the drug, which has become increasingly important in South Africa, explained the National Health Department’s Deputy Director-General for HIV, Yogan Pillay. 

Until today, DTG was only reserved for patients who had grown resistant to standard HIV treatment and needed to move to different and often more expensive regimens, often called second or third-line treatment. The proportion of patients like these is growing. 

“We’re hoping that dolutegravir can help us to decrease the level of resistance and reduce the number of patients who have to move from first to second-line treatment,” said Pillay, speaking at a Bhekisisa policy dialogue in Johannesburg ahead of Mkhize’s announcement. 

DTG rollout in South Africa

Following the public launch on Wednesday, at least five provinces will begin rolling out the new DTG-containing combination before it’s available nationwide by March 2020. The new three-in-one pill will be available to people who have been newly diagnosed with HIV, as well as longtime patients on an efavirenz-containing regimen and who have been virally suppressed for at least six months. 

Mkhize’s announcement comes after 18 months of deliberations by activists, experts and government officials, following news from Botswana that a small number of women taking the DTG drug, gave birth to babies with serious birth defects, known as neural tubal defects. The condition affects the brain, spine or spinal cord. 

But similar studies among about 1 500 Brazilian women on ARVs, a quarter of whom conceived while on dolutegravir, found no birth defects. Scientists are continuing to monitor the phenomenon around the world. 

While the discovery of the birth defects in Botswana stalled a global rollout of DTG, including in South Africa, new evidence, input from women living with HIV globally and the DTG’s benefits led the WHO to greenlight the widespread drug for use in July. 

Patients to be counselled about the drug’s benefits and risks 

In South Africa, concerns around the small, yet the still unconfirmed possibility of birth defects, have prompted the South African Health Products Regulatory Authority to attach additional conditions to the use of DTG in the country.

As part of this, people must be counselled about the drug’s benefits and risks, including possible birth defects and weight gain of about 5 kgs after a year. If they decide the drug is still right for them, patients must sign an acknowledgement of risk at health facilities before starting the new medication. 

Select hospitals have also set up pregnancy registers to detect and report any possible birth defects associated with the rollout.

Ultimately, like the WHO before it, South Africa will not require women living with HIV to be on contraception to get DTG. But ensuring they can make an informed choice about whether DTG is right for them will rest, Pillay admits, on the kind of counselling and contraceptive options available. The department has battled frequent stock-outs of contraception over the last few years. According to Pillay, this is largely because of a limited number of suppliers. 

“Women must have a choice, and no one should make that choice for them,” Pillay concluded.